TRICARE Prime Handbook 2006

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are many resources available to help you. Health Care Services With TRICARE Prime, you will receive most of your care from an assigned primary care manager (PCM). Your PCM can be either a military treatment facility (MTF) provider or a civilian TRICARE network provider. We will discuss your PCM and other provider types later in this handbook. A TRICARE Prime enrollment card and letter have been, or will be, mailed to you. Write your PCM 9s name and telephone number on your enrollment card and refer to this information when you need to make an appointment. 1 Welcome to TRICARE Prime TRICARE North Region The TRICARE North Region includes Connecticut, Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, Wisconsin, and portions of Iowa (Rock Island Arsenal area), Missouri (St. Louis area), and Tennessee (Ft. Campbell area only). TRICARE South Region The TRICARE South Region includes Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area). TRICARE West Region The TRICARE West Region includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal area), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner, including El Paso), Utah, Washington, and Wyoming. TRICARE Prime offers enhanced benefits and personalized care. Look in the mail for the TRICARE Health Matters newsletter, a regular publication for all TRICARE Prime beneficiaries. This publication will highlight covered services, customer service options, news, and other important updates. 2 Regional contractor Health Net Federal Services, Inc. (Health Net) Phone 1 877 TRICARE (1 877 874 2273) Web site www.healthnetfederalservices.com Regional contractor Humana Military Healthcare Services, Inc. (Humana Military) Phone 1 800 444 5445 Web site www.humana military.com Regional contractor TriWest Healthcare Alliance (TriWest) Phone 1 888 TRIWEST (1 888 874 9378) Web site www.triwest.com Your TRICARE Regional Contractor The regional contractors administer TRICARE Prime in each region. We will refer regularly to your regional contractor throughout this handbook, and describe differences in each region. In cases where there are differences, refer to the information specific to your region. We encourage you to visit your regional contractor 9s Web site, which includes information about how to change PCMs, how to enroll a newborn or adopted child, covered and non covered services, referral and authorization requirements, and other helpful information. You can also call your regional contractor toll free for assistance at the numbers listed below. Regional contractors also have TRICARE Service Centers (TSCs) located throughout the region, typically at MTFs, that have customer service representative to assist you. NORTH WEST SOUTH Keep Your DEERS Information Current! It is essential that you keep information in the Defense Enrollment Eligibility Reporting System (DEERS) current for you and your family. DEERS is a worldwide computerized database of uniformed service members (active duty and retired), their family members, and others who are eligible for military benefits, including TRICARE. The key to receiving timely, effective TRICARE benefits 4including doctor appointments, prescriptions, payment of health care expenses, etc. 4is proper and current registration in DEERS. To update DEERS: Important Note for National Guard and Reserve Members and their Families National Guard and Reserve members who are called or ordered to active duty for more than 30 consecutive days become eligible for TRICARE as active duty service members, and family members become eligible for TRICARE as active duty family members. Active duty means full time duty in the active military service of the United States. Throughout this TRICARE Prime Handbook , we will refer to active duty service members and active duty family members. Be aware that we also are referring to activated National Guard and Reserve members and their families enrolled in TRICARE Prime. If you have any questions about TRICARE Prime, contact your regional contractor. 3 " Visit a uniformed services personnel office. Find one near you at www.dmdc.osd.mil/rsl . " Call 1 800 538 9552 . " Fax address changes to DEERS at 1 831 655 8317 . " Mail address changes to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA 93955 6771 " Update addresses online at www.tricare.mil/DEERS . Table of Contents 1.Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Your Primary Care Manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Enrollment Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2.Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Making an Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Access Standards for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Routine (Primary) Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Speciality Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Prior Authorizations for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Getting a Second Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Point of Service Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 3.Covered Services, Limitations, and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Dental Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 4.Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Health Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Pharmacy Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Coordinating Benefits with Other Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Third Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Debt Collection Assistance Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 5.Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Getting Married or Divorced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Having a Baby or Adopting a Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Going to College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Moving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Separating from the Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 Retiring from Active Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Becoming Entitled to Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Deceased Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Loss of Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 4 6.Information and Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Appealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 7.Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 8.Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 9.Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 10.List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 11.Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 For information about your patient rights and responsibilities, see the inside back cover of this handbook. 5 SECTION 1 CHOOSING TRICARE STANDARD/TRICARE EXTRA TRICARE Provider Types TRICARE defines a provider as a person, business, or institution that provides health care. For example, a doctor, hospital, or ambulance company is a provider. Providers must be authorized under TRICARE regulations and have their status certified by the regional contractors to provide services to TRICARE beneficiaries. Military Treatment Facilities A military treatment facility (MTF) is a medical facility (hospital, clinic, etc.) owned and operated by the uniformed services 4usually located on or near a military base. To locate an MTF near you, visit www.tricare.mil/mtf . Civilian Providers Figure 1.1 explains the different types of civilian TRICARE providers. 6 TRICARE Provider Types Figure 1.1 TRICARE-authorized Providers " A provider who meets TRICARE 9s licensing and certification requirements and has been certified by TRICARE to provide care to TRICARE beneficiaries. TRICARE authorized providers include doctors, hospitals, ancillary providers (laboratories and radiology centers), and pharmacies. If you see a provider who is not TRICARE authorized, you are responsible for the full cost of care. " There are two types of TRICARE authorized providers: Network and Non network . Network Providers Non-network Providers " Network providers have a signed agreement with your regional contractor to provide care at a negotiated rate. Network providers file claims for you. " You will receive most of your care from TRICARE network providers. " Non network providers do not have a signed agreement with your regional contractor and are therefore cout of network. d In most cases, you will not receive care from non network providers unless approved by your regional contractor. You may seek care from a non network provider in an emergency or if you are using the point of service (POS) option. " There are two types of non network providers: Participating and Nonparticipating . Participating Nonparticipating " Participating* providers have agreed to file claims for you, to accept payment directly from TRICARE and to accept the TRICARE allowable charge less any applicable cost shares paid by you as payment in full for their services. " Using a participating provider is your best option if you must visit a non network provider. " Nonparticipating providers have not agreed to accept the TRICARE allowable charge or file your claims. If you use the POS option and seek care from a nonparticipating provider, the provider may charge you up to 15% above the TRICARE allowable charge for services (in addition to POS fees). This amount is your responsibility and will not be shared by TRICARE. " If you visit a nonparticipating provider, you may have to pay the provider first and file a claim with TRICARE for reimbursement. Getting Started *Providers may decide to participate on a claim by claim basis. Department of Veterans Affairs Health Care Facilities Many Department of Veterans Affairs (VA) health care facilities participate in TRICARE as network providers. While VA facilities may or may not provide primary care, many do provide specialty care. Be sure to find out the VA facility 9s status as a TRICARE network or non network provider before you receive TRICARE covered health care at a VA facility. Note : Active duty service members who are referred to a VA medical facility for a service connected condition must receive health care benefits under the VA program. When an active duty service member with a service connected condition is referred to/being treated by the VA, the Department of Defense (DoD) is still responsible for payment for the care rendered. Some retired service members may be eligible for both TRICARE and VA benefits (the VA offers health care programs separate from TRICARE 4 refer to the VA Web site at www.va.gov for details), so you will have to choose which program you want to use. When choosing between TRICARE and VA benefits, carefully compare the costs and the financial demands of each option to make the best decision. Your Primary Care Manager When you enrolled in TRICARE Prime, you selected or were assigned a primary care manager (PCM). Your PCM provides your routine health care and coordinates referrals for specialty care that he or she cannot provide. Your PCM may be an MTF provider or a civilian TRICARE network provider within a Prime service area (PSA). A PSA is a geographic area where TRICARE Prime benefits are offered. It 9s typically a geographic area around an MTF and specific areas with a significant concentration of uniformed service personnel and retirees and their families. A PSA must also have a substantial medical community to support most or all TRICARE Prime enrolled beneficiary medical needs. On-Call Providers PCMs are required to provide access to care 24 hours a day, seven days a week. To cover all hours, your PCM may designate an on call provider who will act on their behalf to support your health care needs. Therefore, the information, instructions, care, or care coordination you receive from the on call provider should be treated as if it was coming from your PCM. Changing Your Primary Care Manager You may change your PCM at any time provided the new PCM is accepting new patients and your request complies with local MTF guidelines. Once you have selected a new PCM from your regional contractor 9s provider directory (viewable online at each contractor 9s Web site), complete a TRICARE Prime Enrollment and PCM ChangeForm with the new PCM 9s name and address. You only need to complete the portion of the form related to the PCM change. The change will become effective once the application is received and processed by your regional contractor. You may also call your regional contractor to change your PCM. Once your PCM change is processed, you will be mailed a confirmation letter with the new PCM name and telephone number. 7 SECTION 2 GETTING CARE SECTION 1 GETTING STARTED Enrollment Card You and each enrolled family member will receive his or her own TRICARE Prime enrollment card. Included with the card is a letter identifying your PCM 9s name and telephone number. Write your PCM 9s name and telephone number on your card. TRICARE network providers may require you to show the enrollment card as well as your uniformed services identification (ID) or Common Access Card (CAC) at the time of service. Your TRICARE Prime enrollment effective date is printed on this card. The TRICARE Prime enrollment card does not verify your eligibility for TRICARE. Only your DEERS record can verify eligibility. Disenrollment Enrollment in TRICARE Prime is continuous 4 you do not have to re enroll every year to maintain coverage. Certain events will, however, cause you to be disenrolled from TRICARE Prime. Sponsor Status Change Any change in the sponsor 9s status (e.g., retirement or National Guard and Reserve member deactivation) will cause you to be disenrolled automatically from TRICARE Prime. If you will remain eligible for TRICARE Prime (after the status change), you should submit a new enrollment application to your regional contractor before the status change occurs to avoid a lapse in coverage. Non-Payment of Enrollment Fees If you are required to pay enrollment fees and you do not pay them when due, you will be disenrolled from TRICARE Prime. When disenrolled for non payment, you are subject to a 12 month lockout during which you will not be permitted to re enroll in TRICARE Prime. To avoid missing an appointment, learn about automatic payment options in the TRICARE: Summary of Beneficiary Costs flyer or contact your regional contractor. Becoming Medicare-Eligible at Age 65 When you become entitled to premium free Medicare Part A at age 65, you automatically lose eligibility for TRICARE Prime and become eligible for TRICARE For Life (TFL) if you have Medicare Part B coverage. Visit www.tricare.mil/tfl for more information about TFL. Note : If you are not entitled to premium free Medicare Part A when you become age 65, you remain eligible for TRICARE Prime, Standard, and Extra, and you are not required to have Medicare Part B coverage. You must present a Social Security Administration Letter of Disallowance to an ID card issuing facility to retain TRICARE coverage. Voluntary Disenrollment If you choose to disenroll from TRICARE Prime before the annual enrollment renewal date, you are subject to a 12 month lockout,* during which you will not be permitted to re enroll in TRICARE Prime. You must contact your regional contractor to initiate a voluntary disenrollment. Active duty service members must enroll in either TRICARE Prime or TRICARE Prime Remote. Voluntary disenrollment is not an option. * The 12 month lockout provision does not apply to active duty family members of sponsors grade E 1 through E 4. 8 SAMPLE Name: John Q. Sample Status: Active Duty Sponsor Primary Care Manager: Primary Care Manager Phone: Effective Date: 01 Jan 2000 Valid with presentation of current military ID card Contact your personnel office if any of the above information is incorrect. TRICARE: The World 9s Best Health Care for the World 9s Best Military TRICARE PRIME Loss of Eligibility If you lose your TRICARE eligibility as shown in DEERS, your TRICARE Prime coverage will end automatically. If you believe you are still eligible for TRICARE, you will need to update your DEERS record to re establish your eligibility. Once DEERS is updated, you must re enroll in TRICARE Prime, or you will be covered under TRICARE Standard and TRICARE Extra. If your DEERS record is correct and you have lost eligibility, you may qualify for transitional health care. See the Life Events , cSeparating from the Service dsection for details about transitional health care options. You will receive a certificate of creditable coverage when TRICARE eligibility is lost. See the Life Events , cLoss of Eligibility dsection for more information about the certificate of creditable coverage. 9 SECTION 2 GETTING CARE SECTION 1 GETTING STARTED 10 You receive routine or primary health care from your primary care manager (PCM), and your PCM will refer you to a specialist for necessary specialty care. You are guaranteed access to care within specific time frames, and you may qualify for a travel reimbursement if referred to specialty care that is more than 100 miles from your PCM 9s office. This section explains these and other details about using TRICARE Prime. Making an Appointment Contact your PCM 9s office directly to make an appointment. There is no need to contact your regional contractor to schedule appointments. Access Standards for Care There are certain access standards for care. " The wait time for an urgent care appointment should not exceed 24 hours (one day). " The wait time for a routine appointment should not exceed one week (seven days). " The wait time for a specialty care appointment or wellness visit should not exceed four weeks (28 days). These access standards begin at the time of your call to or contact with the provider. It is important to contact your provider as soon as possible . At times, appointments may not be available within the time frames listed above due to high demand for specialty care services. If the provider does not have appointments available within the access standards, you can choose to schedule the earliest available appointment with the provider or contact your regional contractor for assistance in locating another provider. You should have access to a PCM whose office is within 30 minutes of your home under normal circumstances. Specialty care should be available within one hour from your home. See the section titled, Specialty Care far From Home for information about travel reimbursement if you are referred for specialty care more than 100 miles from your PCM 9s office. Additionally, it is important to understand your provider 9s specific policies regarding cancelled or missed appointments. Some providers charge a missed appointment fee, which is not covered by TRICARE. Please be sure to notify your provider 9s office within the appropriate time, usually 24 to 48 hours prior, if you will not be able to make your scheduled appointment. Emergency Care TRICARE defines an emergency as a medical, maternity, or psychiatric condition that would lead a cprudent layperson d (someone with average knowledge of health and medicine) to believe that a serious medical condition exists, or the absence of immediate medical attention would result in a threat to life, limb, or eyesight, or when the person has painful symptoms requiring immediate attention to relieve suffering. If you need emergency care, go to the nearest emergency room or call 911. It is important that you know the emergency telephone numbers in your area. Take a minute to look these numbers up and write them here or on the inside front cover of this book. Emergency Assistance: _______________________________________ Ambulance: _______________________________________ Poison Control: 1 800 222 1222 You do not need to call your PCM or regional contractor before receiving emergency medical care. However, in all emergency situations, you must notify your PCM within 24 hours, or the next business day, so that ongoing care can be coordinated, and to ensure you receive proper authorization for care. Getting Care 11 SECTION 2 GETTING CARE SECTION 3 COVERED SERVICES, LIMITATIONS, & EXCLUSIONS Urgent Care Urgent care is for an illness or injury that would not result in further disability or death if not treated immediately, but does require professional attention within 24 hours. You would require urgent care for conditions such as a sprain, sore throat, or rising temperature that have the potential to develop into an emergency if treatment is delayed longer than 24 hours. In most cases, you can receive urgent care from your PCM by making a csame day d appointment. If you are away from home, contact your regional contractor for assistance in obtaining urgent care. If you do not coordinate urgent care with your PCM or regional contractor, the care will be covered under the point of service (POS) option, resulting in higher out of pocket costs. See the TRICARE:Summary of Beneficiary Costs flyer to learn about POS fees. Routine (Primary) Care Routine (primary) care includes general office visits for the treatment of symptoms, chronic or acute illnesses and diseases, and follow up care for an ongoing medical condition. Routine care also includes preventive care measures to help keep you healthy. You will receive most of your routine or primary care from your PCM. You do not need a referral to visit your PCM. If your PCM is unable to provide the care needed, he or she will refer you to another provider. If you receive any routine care without a referral from your PCM, you will be utilizing the POS option, resulting in higher out of pocket costs. See the TRICARE:Summary of Beneficiary Costs flyer to learn about POS fees. Services That Do Not Require Referrals Some services may be obtained without a PCM referral. These include clinical preventive services and the first eight outpatient behavioral health care visits per fiscal year (October 1 September 30). When seeking clinical preventive services or behavioral health care, you must use a network provider. If you seek care from a non network provider without a referral from your PCM, you will be utilizing the POS option, resulting in higher out of pocket costs. See the TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees. For more information about these services, see the Covered Benefits , Limitations , and Exclusions section. Remember, you will never need a referral for emergency care. Note : Active duty service members require a referral for any clinical preventive services, behavioral health care, or specialty care. Specialty Care There are times when you will need to see a specialist for a diagnosis or treatment that your PCM cannot provide. Your PCM will provide referrals to access services from specialty providers and will coordinate the referral request with your regional contractor, when necessary. If you receive specialty care without a referral from your PCM, you will be utilizing the POS option, resulting in higher out of pocket costs. See the TRICARE: Summary of Beneficiary Costs flyer to learn about POS fees. Referrals for Specialty Care Visit your regional contractor 9s Web site or call the toll free number to learn about region specific referral requirements and for details about obtaining referrals. If you live near an MTF and are referred for specialty care, inpatient admissions, or procedures requiring prior authorization, your regional contractor will attempt to coordinate your care at the MTF first. When the services are not available at the MTF, the care will be coordinated with a TRICARE network provider. Specialty to Specialty Referrals If your PCM refers you to a specialist who would like to refer you to another specialist, the specialist will need to contact your PCM. Your PCM or the specialist will contact your regional contractor to obtain authorization for additional specialty care, when necessary. Specialty Care Far From Home 4Travel Reimbursement Non active duty TRICARE Prime enrollees who are referred by their PCM for specialty care at a location more than 100 miles (one way) from the PCM 9s office may be eligible to have creasonable travel expenses d reimbursed by TRICARE. Reasonable travel expenses are the actual costs incurred while traveling, including meals, gas/oil, tolls, parking, and tickets for public transportation (i.e., airplane, train, bus, etc.). You must submit receipts for expenses above $75. TRICARE will use government rates to estimate the reasonable cost. You are expected to use the least costly mode of transportation. TRICARE will reimburse the actual costs of lodging (including taxes and tips) and the actual cost of meals (including taxes and tips, but excluding alcoholic beverages) up to the government rate for the area concerned. In some cases, a non medical attendant may also be authorized for travel reimbursement. The non medical attendant must be a parent, guardian, or another adult family member 21 years of age or older. To qualify, you must have a valid referral and travel orders from a TRICARE representative at your MTF (if enrolled to an MTF PCM) or from the TRICARE Regional Office (TRO) (if enrolled to a civilian PCM). You should obtain the travel orders before traveling. Contact your local MTF or TRO travel representative if you think you may qualify for this travel reimbursement. You may also visit the TRICARE Web site at www.tricare.mil/primetravel for more information. Note : Travel for active duty service members is reimbursed through other travel regulations. Active duty service members should contact their unit representatives for information about traveling long distances for medical care. Prior Authorizations for Care A prior authorization is a review of the requested health care service to determine if it is medically necessary at the requested level of care. Prior authorization is required for certain types of care and must be obtained before services are rendered. Your PCM will request prior authorization from your regional contractor when required. If the service is authorized, the regional contractor will give your PCM an authorization number along with specific instructions. For example, prior authorizations for medical or surgical services will have a begin date and end date. Prior authorizations for behavioral health services will specify a number of visits as well as a begin date and end date. You must receive care under the authorization before it expires . If not, you will need to get another referral and authorization from your PCM. 12 TRO-North Visit www.tricare.mil/tronorth or call 1 866 307 9749 TRO-South Call 1 800 554 2397 or 1 210 292 3256 TRO-West Call 1 619 236 5324 TRO Contact Information for Travel Reimbursement Figure 2.1 Services Requiring Prior Authorization Active duty service members require prior authorization for all inpatient and outpatient specialty services. An additional fitness for duty review is required for maternity care, physical therapy, mental/behavioral health services, family counseling, and smoking cessation programs. For all other TRICARE Prime enrollees, the following services require prior authorization in all three TRICARE regions: " Adjunctive dental services " Home health services " Hospice care " Nonemergency inpatient admissions for substance use disorders or behavioral health " Outpatient behavioral health care beyond the eighth visit " Transplants 4all solid organ and stem cell " TRICARE Extended Care Health Option services Each regional contractor has additional prior authorization requirements. Visit your regional contractor 9s Web site or call their toll free number to learn about each region 9s requirements, as they may change periodically. See page 2 for a list of regional toll free numbers. Getting a Second Opinion You have every right to request a consultation with another provider for a second medical opinion when the initial provider is uncertain about a contemplated course of action. You, your PCM, or your regional contractor may request a second medical opinion. If you wish to seek a second opinion, go to your PCM and explain your situation and any questions you may have about the first specialist 9s suggested care. Then, ask your PCM to coordinate a referral to another specialist and request a referral from your regional contractor if necessary. Point of Service Option The TRICARE Prime point of service (POS) option gives you the freedom to seek and receive nonemergency health care services from any TRICARE authorized provider without requesting a referral from your PCM for additional costs. See the TRICARE: Summary of Beneficiary Costs flyer for details about POS fees. The POS option does not apply to the following: " Active duty service members " Newborns or adopted children in their first 60 days " Emergency care " Preventive care services from a network provider " First eight behavioral health outpatient visits from a network provider " If you have other health insurance 13 SECTION 2 GETTING CARE SECTION 3 COVERED SERVICES, LIMITATIONS, & EXCLUSIONS TRICARE Prime covers most care that is medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care are not covered at all. This chapter is not intended to be all inclusive . Visit your regional contractor 9s Web site for additional information about covered services and benefits. Outpatient Services Figure 3.1 provides coverage details for covered outpatient services. Note: This chart is not intended to be all inclusive. 14 Covered Services, Limitations, and Exclusions Service Description Ambulance Services Covers emergency transfers to or from a beneficiary 9s home, accident scene, or other location to a hospital and transfers between hospitals; ambulance transfers from a hospital based emergency room to a hospital more capable of providing the required care; and transfers between a hospital or skilled nursing facility and another hospital based or freestanding outpatient therapeutic or diagnostic department/facility. Excludes ambulance service used instead of taxi service when the patient 9s condition would have permitted use of regular private transportation; transport or transfer of a patient primarily for the purpose of having the patient nearer to home, family, friends, or personal physician; and Medicabs or ambicabs that function primarily as public passenger conveyances transporting patients to and from their medical appointments. Ancillary Services Certain diagnostic radiology and ultrasound, diagnostic nuclear medicine, pathology and laboratory services, and cardiovascular studies. Durable Medical Equipment (DME) Generally covered if medically necessary and appropriate, and if prescribed by a physician for the specific use of the beneficiary. Duplicate items of DME which are essential to provide a fail safe, in home, life support system are covered. In this case, cduplicate d means an item that meets the definition of DME and serves the same purpose but may not be an exact duplicate of the original DME item. For example, a portable oxygen concentrator may be covered as a backup for a stationary oxygen generator . Emergency Services Emergency services are covered for medical, maternity, or psychiatric conditions that would lead a cprudent layperson d (someone with average knowledge of health and medicine) to believe that a serious medical condition exists; that the absence of medical attention would result in a threat to the patient's life, limb, or eyesight; that the patient may be a danger to self or others and requires immediate medical treatment; or that the patient manifests painful symptoms requiring immediate palliative effort to relieve suffering. Eye Examinations " Infants (regardless of beneficiary category): Covered for one eye and vision screening by the PCM during a routine exam at birth and 6 months of age " Active duty service members and family members: Covered for one eye exam per year " All other TRICARE Prime enrollees: Covered for one eye exam every two years " Diabetic patients (regardless of beneficiary category): Covered for one eye exam per year Home Health Care Part time or intermittent skilled nursing services and home health services; physical, speech, and occupational therapy; medical social services; and routine and non routine medical services. All care must be provided by a participating home health care agency and be authorized in advance by the regional contractor. Individual Provider Services Office visits; outpatient office based medical and surgical care; consultation, diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathic manipulation; rehabilitation services (e.g., physical therapy, speech pathology services, and occupational therapy); and medical supplies used within the office. Outpatient Services: Coverage Details Figure 3.1 Inpatient Services Figure 3.2 provides coverage details for covered inpatient services. Note : This chart is not intended to be all inclusive. Clinical Preventive Services Figure 3.3 provides coverage details for clinical preventive services. Note : This chart is not intended to be all inclusive. 15 SECTION 3 COVERED SERVICES, LIMITATIONS & EXCLUSIONS Service Description Laboratory and X ray Services Generally covered if prescribed by a physician (some exceptions apply, e.g., chemo sensitivity assays and bone density X ray studies for routine osteoporosis screening). Papanicolaou (Pap) Smear Covered as either a diagnostic or routine preventive procedure. Note : The HPV Pap test is not covered as a routine screening Pap smear. Prosthetic Devices and Medical Supplies Generally covered if prescribed by a physician and is directly related to a medical condition. Prosthetic devices must be FDA approved. Outpatient Services: Coverage Details (continued) Service Description Hospitalization Semiprivate room (and when medically necessary, special care units), general nursing, and hospital service. Includes inpatient physical and surgical services; meals (including special diets); drugs and medications while an inpatient; operating and recovery room; anesthesia; laboratory tests; X rays and other radiology services; necessary medical supplies and appliances; and blood and blood products. Skilled Nursing Facility Care Semiprivate room; regular nursing services; meals, including special diets; physical, occupational, and speech therapy; drugs furnished by the facility; and necessary medical supplies and appliances. Unlike Medicare, unlimited number of days as medically necessary. Inpatient Services: Coverage Details Figure 3.2 Service Description Health Promotion and Disease Prevention Examinations Office visits may be covered for the following services (subject to age and other criteria): " Cancer screening examinations and services (breast cancer, cancer of female reproductive organs, colorectal cancer, and prostate cancer) " Infectious diseases (Hepatitis B screening, human immunodeficiency virus [HIV] testing) and preventive therapy when at risk (tetanus, animal bite, Rh immune globulin, and exposure to certain infectious diseases, including tuberculosis) " Genetic testing and counseling for certain clinical indications during pregnancy " Other: Routine chest X rays and electrocardiograms required for admission when a patient is scheduled to receive general anesthesia on an inpatient or outpatient basis Immunizations Covered for age appropriate dose of vaccines as recommended by the Centers for Disease Control and Prevention. Immunizations for active duty family members whose sponsors have permanent change of station orders to overseas locations also are covered. Clinical Preventive Services: Coverage Details Figure 3.3 Behavioral Health Care Services Active Duty Service Members Active duty service members must have prior authorization before seeking behavioral health care. We do not want to discourage you from seeing a behavioral health specialist, but we want to make sure that your condition does not adversely affect your health and your ability to perform worldwide duty. Contact your regional contractor before obtaining behavioral health care services. All Others Enrolled in TRICARE Prime You may receive the first eight behavioral health outpatient visits per fiscal year (October 1 September 30) from a network provider without a referral or prior authorization from your PCM. If you obtain these visits from a non network provider without referral from your PCM and your regional contractor, POS fees will apply. After the first eight visits (beginning on the 9th visit), you must obtain a referral from your PCM and receive prior authorization from your regional contractor. Authorized Behavioral Health Providers The following types of behavioral health providers may be authorized providers under TRICARE: " Psychiatrists " Clinical psychologists " Certified psychiatric nurse specialists " Clinical social workers " Certified marriage and family therapists with a TRICARE participation agreement " Pastoral counselors 4with physician referral and supervision " Mental health counselors 4with physician referral and supervision " Licensed professional counselors 4with physician referral and supervision If you are unsure which type of provider would best meet your needs, contact your regional contractor for assistance. 16 Service Description Other Health Promotion and Disease Prevention Services The following services may be covered if provided in connection with a visit for immunizations, Pap smears, mammograms, or examinations for colon and prostate cancer: " Cancer screening (testicular, skin, oral cavity, pharyngeal, and thyroid) " Infectious disease (tuberculosis screening, Rubella antibodies) " Cardiovascular disease (cholesterol screening, blood pressure screening) " Body measurements (height and weight) " Vision screening " Audiology screening (only allowed under well child services) " Counseling services expected of good clinical practice that are included with the appropriate office visit at no additional charge (dietary assessment and nutrition; physical activity and exercise; cancer surveillance; safe sexual practices; tobacco, alcohol, and substance abuse; promoting dental health; accident and injury prevention; and stress, bereavement, and suicide risk assessment) School Physicals Covered for children ages 5 11 if required in connection with school enrollment. Note: Annual sports physicals are not a covered benefit. Well child Services Covered for beneficiaries from birth to age 6; includes visits, immunizations, and vision screening. Clinical Preventive Services: Coverage Details (continued) Figure 3.4 provides coverage details for covered behavioral health care services. Note : This chart is not intended to be all inclusive. 17 SECTION 3 COVERED SERVICES, LIMITATIONS & EXCLUSIONS Service Description Acute Inpatient Psychiatric Care Acute inpatient psychiatric care may be covered on an emergency or nonemergency basis. Prior authorization from your regional contractor is required for all nonemergency inpatient admissions. In emergency situations, authorization is required for continued stay. Limitations " Patients age 19 and older are limited to 30 days per fiscal year.* " Patients age 18 and under are limited to 45 days per fiscal year.* " Inpatient admissions for substance use disorder detoxification and rehabilitation count toward the 30 or 45 day limit. Note : Day limits may be waived if determined to be medically or psychologically necessary (See 10 USC 1079 (i)). Medication Management If you are taking prescription medications for a behavioral health care condition, you must be under the care of a provider who is authorized to prescribe those medications. Your provider will manage the dosage and duration of your prescription to ensure you are receiving the best care possible. Partial Hospitalization Psychiatric partial hospitalization provides interdisciplinary therapeutic services at least three hours per day, five days a week, in any combination of day, evening, night, and weekend treatment programs. " Prior authorization from your regional contractor is required. " Facility must be TRICARE authorized. " Partial hospitalization programs must agree to participate in TRICARE. Limitations " Limited to 60 treatment days (whether a full or partial day treatment) in a fiscal year.* These 60 days are not offset or counted toward the 30 or 45 day inpatient limit. Psychological Testing and Assessment Covered when medically or psychologically necessary and provided in conjunction with otherwise covered psychotherapy. Psychological tests are considered to be diagnostic services and are not counted against the limit of two psychotherapy visits per week. Limitations Testing and assessment is generally limited to six hours in a fiscal year. Exclusions Psychological testing is not covered for the following circumstances: " Academic placement " Job placement " Child custody disputes " General screening in the absence of specific symptoms " Teacher or parental referrals " Diagnosed specific learning disorders or learning disabilities Behavioral Health Care Services: Coverage Details Figure 3.4 * Fiscal year is October 1 September 30. 18 Service Description Psychotherapy Prior authorization is required after the first eight behavioral health outpatient visits per beneficiary per fiscal year.* Covered psychotherapy includes: " Individual, conjoint, family, or group sessions " Collateral visits " Play therapy (This is a form of individual therapy used with children.) " Psychoanalysis (Prior authorization from your regional contractor is required.) Limitations " Outpatient psychotherapy is limited to a maximum of two sessions per week in any combination of individual, family, collateral, or group sessions and is not covered when the patient is an inpatient in an institution. " Inpatient psychotherapy is limited to five sessions per week in any combination of individual, family, collateral, or group sessions. The duration and frequency of care is dependent upon medical necessity. Residential Treatment Center (RTC) Care RTC care provides extended care for children and adolescents with psychological disorders that require continued treatment in a therapeutic environment. " Unless therapeutically contraindicated, the family and/or guardian should actively participate in the continuing care of the patient either through direct involvement at the facility or geographically distant family therapy. " Facility must be TRICARE authorized. " Prior authorization from your regional contractor is required. " RTC care is considered elective and will not be covered for emergencies. " Admission primarily for substance use rehabilitation is not authorized. " Care must be recommended and directed by a psychiatrist or clinical psychologist. Limitations " Limited to 150 days per fiscal year* (limitation may be waived if determined to be medically or psychologically necessary). Note: No qualified RTCs were available in overseas locations at time of printing. Behavioral Health Care Services: Coverage Details (continued) * Fiscal year is October 1 September 30. For additional information about covered and non covered behavioral health care services and how to access care, contact your regional contractor. Pharmacy Services TRICARE offers comprehensive prescription drug coverage and several options for filling your prescriptions. To have a prescription filled, you 9ll need a written prescription and a valid uniformed services identification (ID) or Common Access Card (CAC). Refer to the TRICARE: Summary of Beneficiary Costs flyer or www.tricare.mil/pharmacy for pharmacy cost information. Military Treatment Facility Pharmacy Prescriptions may be filled (up to a 90 day supply for most medications) at an MTF pharmacy at no cost as long as the medication is on the MTF formulary. You should contact the MTF to find out what is on the formulary and for specific details about filling prescriptions at the MTF pharmacy. TRICARE Mail Order Pharmacy The mail order pharmacy is your least expensive option when not using the MTF. You may receive up to a 90 day supply for most medications delivered to your home for a small copayment. Refills may be requested by mail, phone, or online. Express Scripts, Inc. (ESI) administers the mail order pharmacy, and registering is easy. 1. Register online . Complete the registration form and follow the instructions available at www.express scripts.com/TRICARE . 2. Register by phone . Call 1 866 363 8667 . 19 SECTION 3 COVERED SERVICES, LIMITATIONS & EXCLUSIONS Service Description Treatment for Substance Use Disorders A substance use disorder includes alcohol or drug abuse or dependence. TRICARE may cover services for the treatment of substance use disorders, including detoxification, rehabilitation, and outpatient group and family therapy. Emergency and inpatient hospital services are considered medically necessary only when the patient 9s condition is such that the personnel and facilities of a hospital are required. Note: All treatment for substance use disorders requires prior authorization from your regional contractor. Coverage and Limitations " Benefit Period 4Only three substance use disorder treatment benefit periods in a lifetime (waiver possible in accordance with policy criteria) are covered. A benefit period begins with the first date of covered treatment and ends 365 days later, regardless of the total services actually used within the benefit period. Emergency and inpatient hospital services for detoxification, stabilization, and for treatment of medical complications of substance use disorders do not count for purposes of establishing the beginning of a benefit period. " Detoxification 4If chemical detoxification is needed, but does not require the personnel or facilities of a general hospital setting, detoxification services are covered in addition to rehabilitative care. In a diagnosis related group (DRG) exempt facility, detoxification services are limited to seven days per year, unless the limit is waived. " Rehabilitation 4Rehabilitation (residential or partial) is limited to 21 days per year or one inpatient stay in a facility subject to the DRG based reimbursement system, per benefit period; you are limited to three benefit periods in your lifetime. All inpatient stays count toward the 30 or 45 day inpatient limit. " Outpatient Care 4Must be provided by an approved substance use disorder facility in a group setting. Coverage is limited up to 60 visits per fiscal year.* Individual outpatient care for substance use disorder is not covered. " Family Therapy 4Outpatient family therapy is covered beginning with the completionof rehabilitative care. You are covered for up to 15 visits in a benefit period. Behavioral Health Care Services: Coverage Details (continued) * Fiscal year is October 1 September 30. 3.Register by mail . Download the form at www.express scripts.com/TRICARE and mail it to: P.O. Box 52150, Phoenix, AZ 85072 9954. Include the written prescription and the appropriate copayment when you mail your registration. For faster processing of your mail order prescription, you can register before placing your first order. Once you are registered, your provider can fax or call in your prescriptions. ESI will send your medications directly to your home within about 14 days after receiving your prescription. If you have prescription drug coverage from another health insurance plan, you can use the mail order pharmacy if the medication is not covered under the other plan or if you exceed the dollar limit of coverage under the other plan. TRICARE Retail Pharmacy Network You may have prescriptions filled (up to a 30 day supply) at any pharmacy in the TRICARE retail pharmacy network for a small copayment. ESI also administers the retail pharmacy network. For more information or to locate a TRICARE network pharmacy, call 1 866 DoD TRRX (1 866 363 8779) or visit www.express scripts.com/TRICARE . Note : Network pharmacies are available in the United States, Guam, Puerto Rico, and the U.S. Virgin Islands. Non-network Pharmacies Filling prescriptions at a non network pharmacy is the most expensive option. You may have to pay for the total amount first and then file a claim with ESI to receive a partial reimbursement after your deductible is met.(For more information about pharmacy claims, see the Claims section.) Note : Non active duty beneficiaries are using the POS option at non network pharmacies. Quantity Limits and Prior Authorization TRICARE has established quantity limits on certain medications, which means that the DoD will only pay for up to a specified quantity per 30 , 60 , or 90 day supply. Quantity limits are applied to ensure the medications are safely and appropriately used. Exceptions to established quantity limits may be made if the prescribing provider is able to justify medical necessity. Some drugs require prior authorization from ESI. For a general list of prescription drugs that are covered under TRICARE and for drugs requiring prior authorization or having quantity limits, visit www.tricare.mil/pharmacy or call toll free 1 866 DoD TRRX (1 866 363 8779) or 1 866 DoD TMOP (1 866 363 8667) . Generic Drug Use Policy It is DoD policy to use generic medications, instead of brand name medications, whenever possible. Brand name drugs that have a generic equivalent may be dispensed only if the prescribing physician is able to justify medical necessity for use of the brand name drug in place of the generic equivalent. If a generic equivalent drug does not exist, the brand name drug will be dispensed at the brand name copayment. If you insist on having a prescription filled with a brand name drug that is not considered medically necessary, and when a generic equivalent is available, you will be responsible for paying the entire cost of the prescription out of pocket. Non-formulary Drugs Any drug in a therapeutic class determined to be not as relatively clinically effective or not as cost effective as other drugs in the class may be recommended for placement in the third, cnon formulary d tier. Any drug placed into the third tier is available to beneficiaries from the mail order or retail pharmacies, but at a higher cost. You may be able to have non formulary prescriptions filled at formulary costs if your provider can establish medical necessity. To learn more about any medication and common drug interactions, to check for generic equivalents, or to determine if a drug is classified as a non formulary medication, visit the online TRICARE Formulary Search Tool at www.tricareformularysearch.org . 20 For information on how to save money and make the most of your pharmacy benefit, visit www.tricare.mil/pharmacy , or call 1 877 DoD MEDS (1 877 363 6337) . Maternity Services Prenatal care is important, and we strongly recommend that those who are pregnant, or who anticipate becoming pregnant, seek appropriate medical care. TRICARE Prime covers maternity care, including prenatal care, delivery, and postpartum care. Newborns are covered separately. Maternity Ultrasounds TRICARE covers maternity ultrasounds when medically necessary. Such situations include: " Estimating gestational age " Evaluating fetal growth " Conducting a biophysical evaluation for fetal well being " Evaluating a suspected ectopic pregnancy " Defining the cause of vaginal bleeding " Diagnosing or evaluating multiple gestations " Confirming cardiac activity " Evaluating maternal pelvic masses or uterine abnormalities " Evaluating suspected hydatidiform mole " Evaluating the fetus 9s condition in late registrants for prenatal care A physician is not obligated to perform ultrasonography on a patient who is a low risk and has no medical indications. Some providers offer patients routine ultrasound screening as part of the scope of care after 16 20 weeks of gestation. TRICARE does not cover routine ultrasound screening . Only maternity ultrasound with a valid medical indication that constitutes medical necessity is covered by TRICARE. Refer to your regional contractor 9s Web site for additional details on maternity ultrasound coverage. If TRICARE coverage ends during pregnancy, TRICARE will not cover any remaining maternity costs unless your family qualifies for other TRICARE health coverage or has purchased the Continued Health Care Benefit Program (CHCBP). To ensure your newborn is covered by TRICARE, see cHaving a Baby or Adopting a Child d in the Life Events section. Dental Options Active duty service members receive dental care from military dental treatment facilities. For all other beneficiaries, TRICARE offers two dental programs 4the TRICARE Dental Program (TDP) and the TRICARE Retiree Dental Program (TRDP). Each program is administered by a separate dental contractor and has its own monthly premiums and cost shares. TRICARE Dental Program The TDP is a voluntary dental insurance program available to eligible active duty family members and to members of the National Guard and Reserve and/or their families. United Concordia Companies, Inc., (United Concordia) currently administers the program. For information about the TDP, visit the TDP Web site at www.TRICAREdentalprogram.com or call United Concordia toll free at 1 800 866 8499 . TRICARE Retiree Dental Program The TRDP is a voluntary dental insurance program available to retired service members and their eligible family members. Delta Dental Plan of California (Delta Dental) currently administers the program. For information about the TRDP, visit the TRDP Web site at www.trdp.org or call Delta Dental toll free at 1 888 838 8737 . 21 SECTION 3 COVERED SERVICES, LIMITATIONS & EXCLUSIONS Services or Procedures with Significant Limitations Below is a list of medical, surgical, and behavioral health care services that may not be covered unless exceptional circumstances exist. This list is not intended to be all inclusive . Check with your regional contractor 9s Web site for additional information. 22 Service Description Abortions Abortions are covered only when the life of the mother would be endangered if the pregnancy were carried to term. The attending physician must certify in writing that the abortion was performed because a life threatening condition existed. Medical documentation must be provided. Cardiac and Pulmonary Rehabilitation Both are covered only for certain indications. Phase III cardiac rehabilitation for lifetime maintenance performed at home or in medically unsupervised settings is excluded. Cosmetic, Plastic, or Reconstructive Surgery Only covered when used to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance of a severe disfigurement, or after a medically necessary mastectomy. Cranial Orthotic Device or Molding Helmet Cranial orthotic devices are excluded for treatment of nonsynostic positional plagiocephaly. Dental Care and Dental X rays Both are covered only for adjunctive dental care (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical 4not dental 4condition). Education and Training Outpatient diabetic self management and training programs are covered when the services are provided by a TRICARE authorized individual provider who also meets national standards for diabetes self management education programs recognized by the American Diabetes Association (ADA). The provider 9s cCertificate of Recognition d from the ADA must accompany the claim for reimbursement. Eyeglasses or Contact Lenses Active duty service members may receive eyeglasses at MTFs at no cost. For all other beneficiaries, contact lenses and/or eyeglasses are only covered for treatment of: " Infantile glaucoma " Corneal or scleral lenses for treatment of keratoconus " Scleral lenses to retain moisture when normal tearing is not present or is inadequate " Corneal or scleral lenses to reduce corneal irregularities other than astigmatism " Intraocular lenses, contact lenses, or eyeglasses for loss of human lens function resulting from intraocular surgery, ocular injury, or congenital absence Note: Adjustments, cleaning, and repairs for eyeglasses are not covered. Facility Charges for Non Adjunctive Dental Services Covered only to safeguard a patient 9s life. Food, Food Substitutes or Supplements, or Vitamins When used as the primary source of nutritionfor enteral, parenteral, or oral nutritional therapy, intraperitoneal nutrition therapy is covered for malnutrition as a result of end stage renal disease. Services or Procedures with Significant Limitations Figure 3.5 Exclusions In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder) or injury or for the diagnosis and treatment of pregnancy or well baby care. All services and supplies (including inpat

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